Endometritis: Symptoms, Types, Causes and Treatment

Endometritis is a condition that often flies under the radar but has a significant impact on women's reproductive health and overall well-being. Characterized by inflammation of the endometrium—the inner lining of the uterus—endometritis can affect fertility, menstrual health, and quality of life. In this comprehensive article, we explore the key aspects of endometritis, including its symptoms, types, causes, and treatment, using the latest research and clinical insights.

Symptoms of Endometritis

Endometritis can present with a range of symptoms, from obvious and acute to subtle and chronic. Recognizing these symptoms early is crucial for timely diagnosis and effective treatment. While some women experience pronounced signs, others may have only mild discomfort or even be asymptomatic, especially in the case of chronic endometritis.

Symptom	Description	Frequency/Severity	Source(s)
Vaginal Bleeding	Abnormal uterine bleeding, often irregular or prolonged	Very common in chronic form	9
Pelvic Pain	Lower abdominal pain or cramping	Can be acute or mild	8 9
Discharge	Abnormal vaginal discharge, sometimes foul-smelling	May be present	8 9
Fever	Elevated temperature, typically in acute cases	Less common in chronic	8

Table 1: Key Symptoms

Understanding the Presentation of Endometritis

Endometritis symptoms vary depending on whether the condition is acute or chronic.

Acute Endometritis

• Onset: Sudden, typically following childbirth, miscarriage, or procedures involving the uterus.
• Symptoms: Fever, lower abdominal pain, uterine tenderness, and purulent (pus-like) vaginal discharge are hallmark signs. There may also be general malaise and, occasionally, signs of systemic infection 8.
• Other Features: Acute endometritis is characterized histologically by neutrophilic infiltration and microabscess formation in the endometrial lining 8.

Chronic Endometritis

• Onset: More insidious and often underdiagnosed.
• Symptoms: The most common complaint is abnormal uterine bleeding, particularly spotting between periods or after intercourse. Pelvic pain and vaginal discharge may occur but are generally less pronounced than in acute cases 9.
• Other Features: Chronic endometritis may be entirely asymptomatic and only discovered during investigations for infertility or recurrent pregnancy loss 8 9.

Symptom Overlap and Diagnostic Challenges

• Non-specificity: Many symptoms of endometritis overlap with other gynecological conditions, making clinical diagnosis challenging without further testing.
• Silent Cases: Especially in chronic endometritis, the absence of obvious symptoms can result in missed diagnoses, highlighting the need for a high index of suspicion in women with unexplained reproductive issues 8 9.

Types of Endometritis

Endometritis is not a one-size-fits-all condition. It can be categorized based on the duration, severity, and underlying pathology of the inflammation.

Type	Key Features	Population Affected	Source(s)
Acute	Rapid onset, severe symptoms, neutrophil infiltration	Postpartum, post-abortion, post-procedure	8
Chronic	Insidious, mild or silent symptoms, plasma cell infiltration	Women with infertility, abnormal bleeding	8 9

Table 2: Types of Endometritis

Exploring the Subtypes

Acute Endometritis

• Pathology: Characterized by prominent neutrophilic invasion and microabscess formation in the endometrium and uterine cavity 8.
• Typical Triggers: Most commonly arises after events that disrupt the uterine environment, such as childbirth (especially after prolonged labor or cesarean section), miscarriage, or intrauterine procedures like dilation and curettage (D&C) 8.
• Clinical Course: Usually presents as a medical emergency. Prompt treatment is required to prevent complications such as sepsis or spread to pelvic organs.

Chronic Endometritis

• Pathology: Defined by the presence of plasma cell infiltration in the endometrial stroma, along with stromal edema and increased density 9.
• Clinical Associations: Often found in women being evaluated for infertility, recurrent miscarriage, or unexplained abnormal uterine bleeding 8 9.
• Silent Nature: Many cases are only identified during pathological evaluation of endometrial biopsies, highlighting its subtle clinical presentation 8.

Special Considerations

• Overlap: Some women may experience overlapping features, especially if an acute episode transitions into a chronic process.
• Risk Populations: Women with intrauterine devices (IUDs), uterine fibroids (leiomyomas), or recent uterine instrumentation are at higher risk for both types 8 9.

Causes of Endometritis

Understanding what triggers endometritis is essential for both prevention and targeted treatment. The underlying causes can be infectious or non-infectious, and often involve a combination of risk factors.

Cause	Description	Common Contexts	Source(s)
Infection	Bacterial invasion, often polymicrobial	Postpartum, post-abortion, STIs	8
Uterine Procedures	Surgical or diagnostic interventions	Biopsy, D&C, IUD insertion	9
Uterine Abnormalities	Structural changes or growths	Fibroids, polyps	9

Table 3: Causes of Endometritis

Breaking Down the Etiology

Infectious Causes

• Polymicrobial Infections: The most common cause, particularly in acute endometritis. Bacteria from the vaginal flora, such as Escherichia coli, Streptococcus, and anaerobes, ascend into the uterus 8.
• Sexually Transmitted Infections: Pathogens like Chlamydia trachomatis and Neisseria gonorrhoeae can also cause endometritis, often as part of pelvic inflammatory disease 8.
• Postpartum and Post-abortion: After delivery or miscarriage, disruption of the natural barriers allows bacteria to infect the endometrium, especially if there was prolonged labor or retained products of conception 8.

Non-Infectious and Iatrogenic Factors

• Uterine Instrumentation: Procedures such as endometrial biopsy, curettage, or insertion of intrauterine devices can introduce pathogens and cause mechanical injury, increasing the risk 9.
• Uterine Abnormalities: The presence of leiomyomas (fibroids) or polyps may predispose the endometrium to chronic inflammation and infection 9.

Pathophysiology Insights

• Chronic Endometritis: Unlike acute cases, chronic endometritis may not always have an identifiable infectious trigger. It is sometimes associated with subclinical infections or immune dysregulation 8 9.
• Host Response: Individual susceptibility can be influenced by immune status, hormonal milieu, and previous gynecologic history 8.

Treatment of Endometritis

Effective management of endometritis depends on the underlying cause, type, and severity of the condition. The goals are to eradicate infection, resolve symptoms, and prevent complications such as infertility or chronic pelvic pain.

Treatment	Approach	Indications	Source(s)
Antibiotics	Broad-spectrum or targeted therapy	Acute, infectious cases	8
Uterine Evacuation	Removal of retained tissue	Postpartum, post-abortion	8
Treat Underlying	Address structural or procedural risk	Chronic cases, fibroids, IUDs	9
Observation	Follow-up after intervention	Asymptomatic or resolved cases	9

Table 4: Treatment Modalities

Approaches to Management

Acute Endometritis

• Antibiotic Therapy: The cornerstone of treatment. Usually involves broad-spectrum antibiotics to cover aerobic and anaerobic bacteria. Therapy often includes a combination of clindamycin and gentamicin or similar regimens 8.
• Uterine Evacuation: In cases of retained products of conception (after miscarriage or birth), surgical removal may be necessary to eliminate the source of infection 8.
• Supportive Care: Hospitalization, intravenous fluids, and monitoring may be required for severe cases.

Chronic Endometritis

• Tailored Antibiotics: If an infectious agent is identified, a course of targeted antibiotics is prescribed. Doxycycline is commonly used 8.
• Addressing Underlying Factors: Removal of intrauterine devices or treatment of fibroids/polyps may be indicated if these are contributing to the chronic inflammation 9.
• Observation and Follow-up: Chronic endometritis may resolve after biopsy or curettage, and follow-up is recommended to ensure eradication 9.

Special Considerations in Management

• Reproductive Impact: Chronic endometritis is increasingly recognized as a contributor to infertility and recurrent pregnancy loss. Treating the condition may improve reproductive outcomes 8.
• Asymptomatic Cases: Some women, especially those diagnosed incidentally, may not require immediate treatment but should be monitored for symptom development 9.
• Eradication Rates: Studies have shown high rates of resolution after intervention, but recurrence can occur, especially if risk factors persist 9.

Conclusion

Endometritis is a complex and multifaceted condition that can significantly affect women's health. Recognizing its symptoms, understanding its types, identifying underlying causes, and applying evidence-based treatments are essential for optimal outcomes.

Key Points:

• Endometritis presents with symptoms ranging from abnormal bleeding and pelvic pain to subtle or absent signs, especially in chronic cases.
• It is classified as acute (sudden, severe, often infectious) or chronic (insidious, mild or silent, often associated with infertility).
• Causes are commonly infectious (bacterial, post-procedural, postpartum) but may also involve structural uterine abnormalities or iatrogenic factors.
• Treatment centers on antibiotics, removal of infection sources, and addressing underlying risk factors, with high rates of resolution following appropriate therapy.

Awareness and timely management of endometritis can prevent complications and improve reproductive health in affected women.